Do you need a cuppa? Dr. Anushma Sharma ST5 Paediatrics Department of Community Paediatrics Salford AIM 1. Present an interesting case 2. Discuss the outcome 3. Discuss the causes of the presenting symptoms Admission 1 1 year old Vomiting, loose stools, unwell Tachycardiac, irrtable, breathless Metabolic acidosis – pH 7.13, pCO2 2.2, BE -23 , Lac 27, Glu 5.3 Improved quickly within 12 hours with ventilatory support and fluids + sodium bicarbonate correction Metabolic disorder suspected Investigations ammonia acyl carnitine plasma amino acids free fatty acids urine organic and amino acids LFT and renal funtions salicylate levels Admission 2 13 months Had been well Found unresponsive on bedroom floor at 0800 No hypoglycaemia Severe metabolic acidosis pH 6.91, pCO2 2.96, Bicarb 4.3, BE 27.9, lactate>30 Sent to PICU and recovered in 12 hours Skin biopsy and toxicology investigations Previously..... Parents 18 years old, both unemployed, separated H/o domestic violence Good pregnancy NVD No significant neonatal diagnoses Satisfactory growth and development Previously............ 7 weeks old Unwitnessed fall from sofa while being watched by mother's friend Attended A+E promptly Parietal skull fracture Discharged back to mother after child protection investigations 11th admission Recent Burn???? Toxicology Urine positive for Glycolate Antifreeze= Ethylene Glycol Colourless Odourless Very sweet Present in Radiator fluid, Deicer, Wind screen wash, Window cleaning fluid Fake vodka health warning in UK The Guardian, Saturday 31 December 2011 Counterfeit vodka seized by council trading standard teams. Photograph: Nottinghamshire County Council/PA Ethylene Glycol Toxicity Toxic dose requiring medical trematment is 0.1ml/kg body weight or 4 ml for 20 Kg child Lethal dose in humans is 1.4ml/kg or 56 ml for a 20 kg child Ethylene glycol does not evaporate so inhalational exposure is unlikely Ethylene glycol is not absorbed through skin so dermal exposure is also uncommon Outcome Forensic samples obtained Police investigations started and mother was taken in custody BC and sister 10 months old in foster care Metabolism Ethyl alcohol Fomipezole NPIS annual Report 2010-2011 ➲ ➲ Prospective audit Toxic alcohol and glycol cases reported through telephone enquiries to the NPIS in 2010 ➲ Aim: 1. To provide information on the frequency, current management and outcomes of systemic toxic alcohol poisoning. 2. To provide information on which to base the planning of clinical services for this type of poisoning, including appropriate availability of assays and antidotes. Results ➲ ➲ 488 individual exposures 250 in non hospital sourced ➲ ➲ ➲ 89 (18%) cases less than 5 years old 238 in hospital sources 182 potentially systemic exposures ➲ ➲ ➲ 99 (20%) reqiured treartment with antidotes 33 haemodialysis, heamofiltration At least 2 severe cases each week nationally ➲ Main difficulty in management is unavailability of lab assay and inadequate stock of antidote Summary ➲ Glycol and Toxic alcohol toxicity though less common in UK is a significant differntial diagnosis to consider especially in cases of disproportionate metabolic acidosis ➲ It is important to plan and consider how we can treat such a case in our unit, especially when most of us donot stock any of the antidotes Questions?